Partnership working by default: district nurses and care home staff providing care for older people

Older people residents in care homes that only offer residential care rely on primary healthcare services for medical and nursing needs. Research has investigated the demands that care homes staff and residents make on general practice, but not the involvement of other members of the primary healthcare team. This paper describes two consecutive studies completed in 2001 and 2003 that involved focus groups and survey methods of enquiry conducted in two settings: an England shire and inner London. The research questions that both studies had in common were (1) What is the contribution of district nursing and other primary care services to care homes that do not have on‐site nursing provision? (2) What strategies promote participation and collaboration between residents, care home staff and NHS primary care nursing staff? and (3) What are the current obstacles and aids to effective partnership working and learning? A total of 74 community‐based nurses and care home managers and staff took part in 10 focus groups, while 124 care home managers (73% of the171 surveyed) and 113 district nurse team leaders (80% of the 142 surveyed) participated in the surveys. Findings from both studies demonstrated that nurses were the most frequent NHS professional visiting care homes. Although care home managers and district nurses believed that they had a good working relationship, they had differing expectations of what the nursing contribution should be and how personal and nursing care were defined. This influenced the range of services that older people had access to and the amount of training and support care home staff received from district nurses and the extent to which they were able to develop collaborative and reciprocal patterns of working. Findings indicate that there is a need for community‐based nursing services to adopt a more strategic approach that ensures older people in care homes can access the services they are entitled to and receive equivalent health care to older people who live in their own homes.     

The involvement of volunteers in palliative care and their collaboration with healthcare professionals: A cross‐sectional volunteer survey across the Flemish healthcare system (Belgium)

Volunteers occupy a specific space in the delivery of palliative care (PC), addressing specific aspects of care and providing a link between professional healthcare providers and informal care. Engaging and empowering these volunteers can be an important strategy to deliver more integrated and comprehensive PC. Insights into current actual volunteer involvement and collaboration across different healthcare services providing generalist and specialist PC is lacking. This study aims to describe volunteers’ involvement in the organisation of PC, collaboration with professionals and how they evaluate this. A cross‐sectional postal survey of volunteers was conducted between June and November 2018 using a written questionnaire. A two‐step disproportionately stratified cluster randomised sample of 2,273 registered volunteers was taken from different strata of healthcare organisations providing care for people with serious illnesses in the Flemish healthcare system (Belgium). Overall response was 35% (15%–60% for individual strata). About 67% of volunteers were often to always informed about the organisation of patient care and 48% felt the organisation often to always takes their opinion into account, while a minority report having decision rights (18%) or autonomy (24%). For some, their organisation failed to inform (17%), consult (27%), take into account their opinion (21%), give them decision rights (20%) or autonomy (16%) over certain aspects of patient care provision often enough. Overall, volunteer–professional collaboration was low, and mostly limited to information sharing. Dedicated PC volunteers collaborated extensively with nurses, often involving task coordination (46%). Ambiguity regarding tasks, agreements and/or rules (15%) and lack of information exchange (14%) were the most cited barriers to volunteer–professional collaboration. Many volunteers were open to stronger involvement in the organisation of care in PC services. Collaboration with professionals seemed lacking in width and depth. Particularly, nursing home volunteers indicated a desire and large potential for more involved and collaborative roles in PC provision.     

Unmet home healthcare needs and quality of life in cancer patients: a hospital‐based Turkish sample

Home healthcare services in Turkey are provided primarily to patients that are bedridden or seriously disabled. There are no such services integrated with hospital services that are specifically designed for cancer patients. The present study aimed to explore the home healthcare needs of cancer patients and their experiences related to unmet home healthcare needs. The study included 394 adult cancer patients who were followed up at the surgical oncology department of a university hospital. A 37‐item, study‐specific questionnaire and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for cancer patients (EORTC‐QLQ‐C30) were administered, and patient clinical records were evaluated. Home healthcare was provided primarily by the patients' immediate family members; the professional home healthcare usage rate was only 2.8%. Patient quality of life (QoL) was negatively affected by cancer, especially those with stage three and four disease. The frequency of the need for home healthcare services due to disease‐related health problems during the 30 days prior to administration of the questionnaires was as follows: pain (62.9%), surgical wound care (44.9%), injection of therapeutics (52.3%), gastrointestinal complaints (51.8%), anxiety (87.1%), psychosocial assistance (77.2%) and information about cancer (94.4%). In the absence of home healthcare services, the patients primarily used institutional healthcare services to meet their needs; otherwise, their needs were not met. The physical and psychosocial problems that cancer patients experience could be solved in most cases by professional home healthcare services. Hospital‐integrated home healthcare services might not only improve cancer patient QoL but might also increase the effectiveness of hospital‐based healthcare services.     

Rapid evidence assessment of approaches to community neurological nursing care for people with neurological conditions post‐discharge from acute care hospital

Neurological conditions represent leading causes of non‐fatal burden of disease that will consume a large proportion of projected healthcare expenditure. Inconsistent access to integrated healthcare and other services for people with long‐term neurological conditions stresses acute care services. The purpose of this rapid evidence assessment, conducted February–June 2016, was to review the evidence supporting community neurological nursing approaches for patients with neurological conditions post‐discharge from acute care hospitals. CINAHL Plus with Full Text and MEDLINE were searched for English‐language studies published January 2000 to June 2016. Data were extracted using a purpose‐designed protocol. Studies describing community neurological nursing care services post‐discharge for adults with stroke, dementia, Alzheimer's disease, Parkinson's disease, multiple sclerosis or motor neurone disease were included and their quality was assessed. Two qualitative and three quantitative studies were reviewed. Two themes were identified in the narrative summary of findings: (i) continuity of care and self‐management and (ii) variable impact on clinical or impairment outcomes. There was low quality evidence of patient satisfaction, improved patient social activity, depression scores, stroke knowledge and lifestyle modification associated with post‐discharge care by neurological nurses as an intervention. There were few studies and weak evidence supporting the use of neurology‐generalist nurses to promote continuity of care for people with long‐term or progressive, long‐term neurological conditions post‐discharge from acute care hospital. Further research is needed to provide role clarity to facilitate comparative studies and evaluations of the effectiveness of community neurological nursing models of care.     

六西格玛管理法对妇产科优质护理病房护理质量、成本管理的影响研究

目的：分析六西格玛管理法对妇产科优质护理病房护理质量、成本管理的影响。方法选择在本院妇产科优质护理病房接受治疗的不同时期患者作为研究对象,分别接受常规管理及六西格玛管理法,观察两组病历书写时间、医嘱处理时间、护理质量、满意度、住院时间、住院费用。结果观察组病历书写时间（65．32±6．57）min、医嘱处理时间（135．24±12．05）min,明显低于对照组;护理质量（95．62±7．54）、患者满意度（92．15±8．76）、护士满意度（94．44±10.21）、单日费用（900．97±135．64）,明显高于对照组。结论六西格玛管理法能够减少护士间接工作时间,提高护理质量,增加床位利用率,实现医、患双赢的目的。     

老年护理医院病人长期护理服务模式的研究

我国老年护理实践起步晚,患者在老年护理医院需要接受何种护理服务,并没有明确的标准。本文分析了我国老年护理医院长期护理服务模式的发展现状和存在不足,提出老年护理医院应建立针对老年、慢性病、临终关怀患者的长期医疗护理服务模式,从转变传统护理服务观念,探索助理护士管理模式,合理配置护理人力资源,建立老年护理质量评价体系等方面着手,构建适合国情的老年护理医院长期护理服务模式的建议,对提高老年护理病人生活质量和促进护理事业发展具有现实意义。     

Cancer care at home or in local health centres versus in hospital: Public policy goals and patients’ preferences in the Rhône-Alps region in France

In France, cancer treatments are mainly provided in hospitals, which are expensive and crowded. Health decision-makers therefore want to develop alternative structures such as home care and local health centres.ObjectivesTo elicit cancer patients’ preferences for home, local health centre, or hospital, and analyze factors affecting these choices: patients’ characteristics, experiences of care, expectations and perceptions of cancer management.MethodsWe developed a decision aid composed of 1) information on the 3 options 2) a questionnaire to measure preferences; 3) a questionnaire on sociodemographics and experiences of care, 386 patients participated in the survey.Resultshospital was the preferred option for 71 % of the participants, especially for complicated care, followed by home care (24 %) and local health centres (5%). Main reasons for preferring hospital were the wish to separate home life and place of care, wanting to avoid being a burden on their relatives. Reasons influencing a preference for home care were wanting to avoid trips, maintain their lifestyle, and finding hospitals frightening. Neither socio-demographics nor even experience of care seemed to explain preferences.ConclusionA quarter of patients preferred home care, which is highly disproportionate to the home care currently available. This suggests that hindrances to developing alternatives to hospital do not come from patients’ reluctance to make use of them, but rather from healthcare providers’ objections.     

Mixed care networks of community‐dwelling older adults with physical health impairments in the Netherlands

As part of long‐term care reforms, home‐care organisations in the Netherlands are required to strengthen the linkage between formal and informal caregivers of home‐dwelling older adults. Information on the variety in mixed care networks may help home‐care organisations to develop network type‐dependent strategies to connect with informal caregivers. This study first explores how structural (size, composition) and functional features (contact and task overlap between formal and informal caregivers) contribute to different types of mixed care networks. Second, it examines to what degree these network types are associated with the care recipients' characteristics. Through home‐care organisations in Amsterdam, the Netherlands, we selected 74 frail home‐dwelling clients who were receiving care in 2011–2012 from both informal and formal caregivers. The care networks of these older adults were identified by listing all persons providing help with five different types of tasks. This resulted in care networks comprising an average of 9.7 caregivers, of whom 67% were formal caregivers. On average, there was contact between caregivers within 34% of the formal–informal dyads, and both caregivers carried out at least one similar type of task in 29% of these dyads. A principal component analysis of size, composition, contact and task overlap showed two distinct network dimensions from which four network types were constructed: a small mixed care network, a small formal network, a large mixed network and a large formal network. Bivariate analyses showed that the care recipients’ activities of daily living level, memory problems, social network, perceived control of care and level of mastery differed significantly between these four types. The results imply that different network types require different actions from formal home‐care organisations, such as mobilising the social network in small formal networks, decreasing task differentiation in large formal networks and assigning co‐ordination tasks to specific dyads in large mixed care networks.     

Reconciling economic concepts and person‐centred care of the older person with cognitive impairment in the acute care setting

Person‐centred care is a relatively new orthodoxy being implemented by modern hospitals across developed nations. Research demonstrating the merits of this style of care for improving patient outcomes, staff morale and organizational efficiency is only just beginning to emerge. In contrast, a significant body of literature exists showing that attainment of person‐centred care in the acute care sector particularly, remains largely aspirational, especially for older people with cognitive impairment. In previous articles, we argued that nurses work constantly to reconcile prevailing constructions of time, space, relationships, the body and ethics, to meet expectations that the care they provide is person‐centred. In this article, we explore key concepts of neo‐liberal thought which forms an important back‐story to the articles. Economic concepts, “efficiency” and “freedom” are examined to illustrate how nurses work to reconcile both the repressive and productive effects of economic power. We conclude the article by proposing a new research agenda aimed at building a more nuanced understanding of the messy actualities of nursing practice under the influences of neo‐liberalism, that illuminates the compromises and adaptations nurses have had to make in response to economic power.     

Task shifting in the provision of home and social care in Ontario,Canada: implications for quality of care

Growing healthcare costs have caused home‐care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home‐care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home‐care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010–2011. Using a purposive sampling strategy, semi‐structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home‐care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G‐tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust‐based relationships with clients; and because task shifting reduced the number of care providers entering the client's home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed.     

Hospital staffing, organization, and quality of care: cross-national findings.

OBJECTIVE: To examine the effects of nurse staffing and organizational support for nursing care on nurses' dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals. DESIGN: Multisite cross-sectional survey. SETTING: Adult acute-care hospitals in the United States (Pennsylvania), Canada (Ontario and British Columbia), England, and Scotland. STUDY PARTICIPANTS: 10 319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Nurse job dissatisfaction, burnout, and nurse-rated quality of care. RESULTS: Dissatisfaction, burnout, and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support. CONCLUSION: Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.     

The impact of a complex care clinic in a children's hospital

Background The number of medically complex and fragile children (MCFC) cared for in children's hospitals is growing, necessitating the need for optimal care co‐ordination. The purpose of this study was to describe the impact of a nurse practitioner/paediatrician‐run complex care clinic in a tertiary care hospital on healthcare utilization, parental and primary care provider (PCP) perceptions of care and parental quality of life. Methods MCFC and their parents were recruited for ambulatory follow‐up by the hospital team to complement care provided by the PCP in this mixed methods single centre pre‐ or post‐evaluative study. Parents participated in semi‐structured interviews within 48 h of discharge; further data were collected at 6 and 12 months. Healthcare utilization was compared with equal time periods pre‐enrolment. Parental health was assessed with the SF‐36; parental perceptions of care were assessed using the Larsen's Client Satisfaction Questionnaire and the Measure of Processes of Care; PCPs completed a questionnaire at 12 months. Parental and PCP comments were elicited. Comparisons were made with baseline data. Results Twenty‐six children and their parental caregivers attended the complex care clinic. The number of days that children were admitted to hospital decreased from a median of 43 to 15 days, and outpatient visits increased from 2 to 8. Mean standardized scores on the SF‐36 increased (improved) for three domains related to mental health. A total of 24 PCPs responded to the questionnaire (92% response); most found the clinic helpful for MCFC and their families. Parents reported improvements in continuity of care, family‐centredness of care, comprehensiveness and thoroughness of care, but still experienced frustrations with access to services and miscommunication with the team. Conclusion A collaborative medical home focused on integrating community‐ and hospital‐based services for MCFC is a promising service delivery model for future controlled evaluative studies.     

Does older adults’ use of social care influence their healthcare utilisation? A systematic review of international evidence

Improving our understanding of the complex relationship between health and social care utilisation is vital as populations age. This systematic review aimed to synthesise evidence on the relationship between older adults’ use of social care and their healthcare utilisation. Ten databases were searched for international literature on social care (exposure), healthcare use (outcome) and older adults (population). Searches were carried out in October 2016, and updated May 2018. Studies were eligible if they were published after 2000 in a high income country, examined the relationship between use of social care and healthcare utilisation by older adults (aged ≥60 years), and controlled for an indicator of need. Study quality and bias were rated using the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross‐Sectional Studies. Study data were extracted and a narrative synthesis was conducted. Data were not suitable for quantitative synthesis. Thirteen studies were identified from 12,065 citations. Overall, the quality and volume of evidence was low. There was limited evidence to suggest that longer lengths of stay in care homes were associated with a lower risk of inpatient admissions. Residents of care homes with onsite nursing had fewer than expected admissions to hospital, compared to people in care homes without nursing, and adjusting for need. Evidence for other healthcare use outcomes was even more limited and heterogeneous, with notable gaps in primary care. We conclude that older adults’ use of care homes may moderate inpatient admissions. In particular, the presence of registered nurses in care homes may reduce the need to transfer residents to hospital. However, further evidence is needed to add weight to this conclusion. Future research should build on this evidence and address gaps regarding the influence of community based social care on older adults’ healthcare use. A greater focus on primary care outcomes is imperative.     

震后基层医院护理人员现状及需求调查与分析

目的了解震后基层医院护理人员现状及需求。方法采用调查问卷,对基层医院护理人员的个人信息、收入、工作环境、继续教育需求等进行调查。结果震后基层医院人力资源配置状况不良,职称比例失衡,编制不足,人员需求增加（65．7％）;收入低,要求改善待遇（84．9％）;赞同从技术、培训方面采用派人常驻、分批分期、提供免费进修等形式进行对口帮扶（83．4％）;需要到上级医院进修深造（96．1％）;希望通过外出参加业务培训或学术交流来提高自身专业水平（93．2％）。结论相关部门应加强人才建设,制定对口支援措施,建立激励与补偿机制,调整职称结构,提升护士的护理综合能力,满足群众对护理服务的需求。     

Ideal and reality; Community healthcare professionals’ experiences of user‐involvement in reablement

Many welfare states offer reablement, also known as restorative care, as an intervention to promote healthy ageing and support older adults in regaining or maintaining their independence in daily life. Reablement is a time‐limited, intensive, multidisciplinary, person‐centred and goal‐directed rehabilitative intervention. Reablement emanates from the user’s goals, thus user‐involvement is a key factor. The aim of our study was to explore healthcare professionals’ experiences of user‐involvement in reablement. The context for the study was an urban municipality in south‐eastern Norway where reablement had been implemented into home‐care services 1.5 years prior to the study. Eighteen healthcare professionals recruited from home‐care services participated in focus groups. The material was analysed using qualitative content analysis. The findings resulted in one main theme: Transforming user‐involvement from ideal to reality—a demanding process, and four sub‐themes: (a) An ideal of self‐determination and co‐operation; (b) Diverse ability to commit to what user‐involvement requires; (c) Continuous co‐creation processes; and (d) Challenged by old traditions. User‐involvement is a valued ideal that professionals strive towards when providing healthcare. Two main strategies that professionals use to enable user‐involvement were identified here: spending sufficient time and having patience with users during the initial stage of an intervention, and starting an intervention by introducing small tasks that users can master. It was also seen that if the time and arenas for interdisciplinary meetings were lacking, professionals could demonstrate traditional attitudes and practice when faced with limited user‐involvement in the intervention. There is a need for follow‐up over time at the structural, personal, and cultural levels to develop reablement as an intervention with a strong person‐centred approach. The findings of this study have relevance for practice development in several reablement settings.     

Carers' reflections on nursing home and NHS long-stay care for elderly patients

The aim of this study was to compare the perceptions of carers of elderly long-stay care patients who are now in nursing homes in three health districts in a former Regional Health Authority and in remaining long-stay geriatric National Health Service (NHS) wards. One hundred and ninety-eight nursing home carers (78%) and 128 NHS carers (83%) were interviewed by telephone, using a semi-structured questionnaire and open questions. The impact of caring at home was shown to be greater on NHS than on nursing home carers. Most were satisfied with the care, staff and atmosphere of the nursing home or hospital. Nursing homes were perceived to offer better ‘hotel’ facilities and a more pleasant environment. They were seen as better at respecting patients' privacy. The NHS was regarded as superior in offering clinical and rehabilitative services. Most participants thought the institution was the right place for their relative, although in general, it was thought to be better to care for elderly people at home. ‘Care in the community’ was supported, but carers were realistic about alternatives when informal care ceased to be a reasonable option. There was little ‘choice’ between public and private sector care. For many patients, entry into the institution followed directly from an acute hospital admission. The only choice was between care in a long-stay facility or remaining at home, with the patient becoming increasingly dependent and the carer becoming increasingly unable to cope. The formal aspect of community care should be to be organized rationally and accepted as a valid response to the needs of some dependent elderly patients and their carers.     

An integrative review on family caregivers’ involvement in care of home‐dwelling elderly

Often family members provide care‐giving, which allows older adults to remain in their homes. With declining health and increasing frailty, care‐giving of elderly people becomes a task of family caregivers (FC) in conjunction with home care nurses. It has been shown in both acute care settings and long‐term care facilities that family members prefer to be involved in decision‐making and care planning for their next of kin. Therefore, an integrative review was conducted to explore the body of knowledge of FCs’ involvement in home‐care settings from the FCs’ perspective. CINAHL, PubMed, and Cochrane databases was searched with the terms family caregiver, involvement, home care, and community dwelling. Studies written in German or English between 1996 and 2017 focusing on FCs’ caring for home‐dwelling older adults together with home care nurses were included and critically appraised. The extracted findings were analysed with concept analysis method. Twenty‐six studies were included and five themes were identified. Four themes formed the basis of assistance towards family caregivers by nurses and included “relationship building with professionals,” “negotiating with professional care,” “being professionally supported,” and “managing role expectations and knowledge sharing”. The fifth theme, “working together” described the mutual care for the care recipient. Although the first four themes were consistent with a pre‐existing conceptual model by Sims‐Gould and Marin‐Matthews (2010), the fifth required an expansion of the model with an additional contribution “collaborative practice”. The findings illustrate that involvement in care is an interactional process, which provides the basis for collaborative practices with the home care nurses for family caregivers. Family members often want to be part of the healthcare team, and nurses need contextual factors that allow providing their full range of skills and knowledge to involve family caregivers accordingly.     

Does integrated governance lead to integrated patient care? Findings from the innovation forum

Good integration of services that aim to reduce avoidable acute hospital bed use by older people requires frontline staff to be aware of service options and access them in a timely manner. In three localities where closer inter‐organisational integration was taking place, this research sought patients’ perceptions of the care received across and within organisational boundaries. Between February and July 2008, qualitative methods were used to map the care journeys of 18 patients (six from each site). Patient interviews (46) covered care received before, at the time of and following a health crisis. Additional interviews (66) were undertaken with carers and frontline staff. Grounded theory‐based approaches showed examples of well‐integrated care against a background of underuse of services for preventing health crises and a reliance on ‘traditional’ referral patterns and services at the time of a health crisis. There was scope to raise both practitioner and patient awareness of alternative care options and to expand the availability and visibility of care ‘closer to home’ services such as rapid response teams. Concerns voiced by patients centred on the adequacy of arrangements for organising ongoing care, while family members reported being excluded from discussions about care arrangements and the roles they were expected to play. The coordination of care was also affected by communication difficulties between practitioners (particularly across organisational boundaries) and a lack of compatible technologies to facilitate information sharing. Finally, closer organisational integration seemed to have limited impact on care at the patient/practitioner interface. To improve care experienced by patients, organisational integration needs to be coupled with vertical integration within organisations to ensure that strategic goals influence the actions of frontline staff. As they experience the complete care journey, feedback from patients can play an important role in the service redesign agenda.